Stewardship is the key

The key to better management of antibiotic use, said Roselle, is proper antimicrobial stewardship – which means treating the right patient with the right dose at the right time. VA’s efforts in this area have been much more global than addressing one drug or one class of drugs – and they have met with some success.

“We probably started full force with a program to decrease MRSA in VA in 2006 with education modules,” Roselle recounted, noting that the effort has increased and spread nationwide and has culminated in the paper that was recently published in the New England Journal of Medicine.

From October 2007 to June 2010, the period of the study, the percentage of patients who were screened at admission increased from 82% to 96%, and the percentage who were screened at transfer or discharge increased from 72% to 93%. While the rates of healthcare–associated MRSA infections in ICUs had not changed in the two years before October 2007, they declined 62% with the implementation of the bundle, dropping from 1.64 infections per 1,000 patient-days in October 2007 to 0.62 per 1,000 patient-days in June 2010. During the same period, the rates of healthcare–associated MRSA infections in non-ICUs fell from 0.47 per 1,000 patient-days to 0.26 per 1,000 patient-days, or a decrease of 45%.

“That’s what I call a dramatic decrease in MRSA,” Roselle asserted.

Identifying Best Practices

One of the challenges going forward, he said, is that there is not necessarily a single set of best practices that can be used to address all drug-resistant bacteria. “The program for MRSA concluded that emphasis on hand-washing, nasal cultures on admission and proper isolation were effective, but it’s not entirely clear that each of those would be necessary for other organisms,” he says. For example, he noted, routine cultures are not necessary for C. difficile, so there will clearly be differences in best practices when looking at specific organisms.

On the other hand, he continued, the antibiotic-stewardship program takes a more global approach and is not organism-specific. “Rather, it deals with appropriate use,” he explains. “But it’s too early yet for us to identify the keys to appropriate use.”

“Antibiotic organism resistance and usage is very important to the National Infections Program Office, and we are very actively putting programs in place to have better stewardship of antimicrobial practices and reduced resistance,” added Kelly.